As a recent US med grad, I get tired of headlines emphasizing the money aspect of specialization. For me, the defining factor is getting a chance to actually feel like a doctor in a specialty where I can spend more than 12 minutes with a patient (psychiatry). Treating a huge number of elderly, comorbid patients in a mediocre fashion is not what most of us went into medicine for. These patients need more time, not less, but a clinic funded primarily Medicare would quickly go under if the physician spent the appropriate amount of time with them.posted by fraxil at 7:09 PM on November 18, 2008 [1 favorite]

And yet... specialists do make much, much more money.

Fraxil, would you have chosen the same specialty if all doctors were paid on the same scale? Or at worst, if +2 years meant a 20 percent higher salary, rather than 1800%? (You may have, and if so great, but you must also accept that many many of your classmates were probably making decisions with dollar signs strongly factored in. And with the job market the way it is, why shouldn't they?)

As a society, we don't value primary care very highly. Similarly, we don't value teachers. So overall, GP's are underpaid, also like teachers. We have a bad education system in America, and bad primary health care. It's a pretty direct relationship, I think.

(Of course, I have no solution handy.)posted by rokusan at 7:23 PM on November 18, 2008

Primary care is no longer covered by regular insurance. Federal bean counters pick a number for appointment charges that's enough to run a decent practice off, make a moderate income and hire some administrative staff. Index it by state or give a bonus for rural practices if you want but pick a number. Let's say $30 for every 15 minute appointment.

Stick another 0.5% on everyone's taxes. For a poor person working minimum wage that's going to be less than $50/year. Then every doctor's visit is subsidised by the amount. Doctors are free to go over that number for people who can afford it (i.e. Don't have a job or work minimum wage? $30. Have a decent job? That'll be $45 please). Don't like the price? Find a cheaper doctor. There will still be competiton. Everyone gets paid exactly what they want, "free" clinics will get a decent amount of remuneration for once while poor people still get a decent standard of care.

Now the doctors only have co-pay numbers that they themselves can set. They only have one agency to deal with in order to get paid, they know exactly how much they're going to be subsidised and they only have one set of red tape. Yes they'll still need to fight with insurance companies over specialist procedures but it's a start, it's fairly cheap and it retains the freedom of doctors to compete and make a reasonable profit while providing a safety net to the poorest residents of the country.posted by Talez at 7:37 PM on November 18, 2008

And yet, if we had a well-implemented single-payer system many of the headaches would be reduced or eliminated. No more uncompensated care, no more complicated insurance billing, no more sending unpaid bills to collections, etc. True, doctors might make somewhat less money overall, but if what they're really concerned about is having the time to provide good care for their patients, then that shouldn't bother them too much.

Unfortunately, the AMA opposes a single-payer system, favoring a subsidized insurance scheme like the one that McCain proposed. I have to say I don't really understand why so many doctors take the position they do. For example, I know an ER doctor who opposes a single-payer system despite the fact that uncompensated care is one of the biggest problems for emergency departments.

It's worth noting that the number of doctors who would choose another career given the chance has been steadily rising for years and years. One of the specialties that typically tops that chart is pediatrics. Apparently working with sick kids isn't so great (to be fair, most of the problem is dealing with the parents of sick kids).posted by jedicus at 7:38 PM on November 18, 2008 [2 favorites]

Isn't MD a 6ish year undergrad degree in most civilized nations? Doesn't the AMA oppose this simply because they enjoy the limit on supply? Well, those nations also pay for medical school.posted by jeffburdges at 7:41 PM on November 18, 2008

Doctor: I have some bad news and some very bad news.
Patient: Well, might as well give me the bad news first.
Doctor: The lab called with your test results. They said you have 24 hours to live.
Patient: 24 HOURS! That's terrible!! What could be WORSE? What's the very bad news?
Doctor: I've been trying to reach you since yesterday.posted by netbros at 7:42 PM on November 18, 2008 [4 favorites]

rokusan, I would support a salary for all physicians in the US, adjusted for years of training and complexity of their patients similar to the British system. Good luck getting that past the AMA. If we are going to go down that path we might as well have the government reimburse all medical tuition nationwide, a fraction of our overall healthcare spending. I am skeptical that students would choose to pursue primary care even if debt and reimbursement were an issue because of the horrendous and soul-numbing managerial and bureaucratic aspects of primary care. I really do think we need a British system with good EMR (the VA hospital system already has an excellent system in place), salaries, and true pay-for-performance (the current P4P system costs more in time lost documenting than it rewards).

I do think that it would be a bad idea to condense college and medical training into a 6 year program. Do we really want to sacrifice the broader humanistic training that an english or philosophy major can bring to medicine and make it into an entirely technically-focused career? My understanding regarding the shortage of medical school seats is that as recently as the 90's there was a predicted oversupply of physicians and many schools reduced class sizes. That is now being reversed and new schools are being opened.posted by fraxil at 7:50 PM on November 18, 2008

No Talez, price fixed or means tested care is bureaucratic & low quality care (see England). Instead merely let the state & federal governments set their payout amount and copay for each activity, operation, etc. All doctors remain free to set their own prices above the state plus federal payouts, but those payouts are handled from once centralized system which is simple, free, and also handles medical records.

Otoh, you should also require doctors claiming federal or state reimbursement to account for the time spent handling private insurance and charge more for insured patients accordingly, but charging rich people more for exactly the same service should be forbidden (although "luxury care" need not be forbidden).posted by jeffburdges at 7:56 PM on November 18, 2008

No fraxil, trust me, you don't want the ridiculous British system. You want the French system where doctors still operate under the free market, but there is a single payer (see previous comment).posted by jeffburdges at 7:58 PM on November 18, 2008 [1 favorite]

We'd be less likely to burn out if people would stop coming to us with their problems.posted by docpops at 8:02 PM on November 18, 2008 [4 favorites]

As someone who has lived for years in both countries, I think that primary and emergency care is superior in England to what insure people get in the U.S. (not even considering the uninsured for which the U.S. system sucks even worse). I'm not saying that the French system isn't better, but I think there is a lot of misplaced fear of the English system. If U.S. primary care were more like the British system, it would be an improvement.

As for bureaucratic care, here is no health care system more bureaucratic than the one in the United States.posted by grouse at 8:10 PM on November 18, 2008 [1 favorite]

WHAT'S WRONG? TOO MUCH PAY FOR PROCEDURES, NOT ENOUGH PAY FOR TIME!!!!!!!!!!!!!posted by caddis at 8:10 PM on November 18, 2008

My previous comment is missing the following letters: d, tposted by grouse at 8:15 PM on November 18, 2008 [1 favorite]

Cuba has been providing doctors for much of central and south america. Maybe they just need to look north now.posted by shetterly at 8:16 PM on November 18, 2008 [2 favorites]

I was comparing England vs. France not the U.S. France doesn't tell doctors what they can charge the customer, just what they'll be paid by the single payer and the copay. France also pays for medical school. But ordinary capitalism keeps most French GPs charging only the required copay.posted by jeffburdges at 8:19 PM on November 18, 2008

Yes, Fraxil, you sound like the (good) doctors and med students I know, the ones who aren't subscribing to Ferrari magazines.

I have also heard that the AMA wants to restrict supply in order to drive up doctor salaries and keep them high. That's their job, I suppose, but it's sort of icky.posted by rokusan at 8:33 PM on November 18, 2008

No Talez, price fixed or means tested care is bureaucratic & low quality care (see England). Instead merely let the state & federal governments set their payout amount and copay for each activity, operation, etc. All doctors remain free to set their own prices above the state plus federal payouts, but those payouts are handled from once centralized system which is simple, free, and also handles medical records.

Heh. That's exactly what I meant. I guess it helps if I put it in context. This is basically what happens over here in Australia. I go to the doctor, I pay $50 AUD. I go to Medicare and get AUD$32.80 back. However, the doctors are nice people and if you have a concession card to say you're dirt poor they do something called "bulk billing" where they just accept the going Medicare rate and you can go to the doctor without paying a cent.

This is what America needs. Subsidized insurance just lines the pockets of the private system without removing any complexity. Truly single payer will only drive doctors out of the industry when the fed cuts the going rate to the bone. The solution is a defacto federal run insurance scheme which pays a certain amount towards a medical visit and allows the doctor to still charge their own rates in a capitalist society.

But ordinary capitalism keeps most French GPs charging only the required copay.

We have ordinary capitalism here and for people capable of paying doctors will get charged much more than the going Medicare rate simply so that the practices can survive.posted by Talez at 8:36 PM on November 18, 2008

Nearly half the respondents in a survey of U.S. primary care physicians said that they would seriously consider getting out of the medical business within the next three years if they had an alternative.

I bet nearly half the people in almost any profession (and especially the gripers who would bother to respond to such a survey) would "seriously consider getting out of" that profession if they had an alternative.

But if there's a real shortage of primary care physicians, link student loan and aid deals to whether you're working as a primary care physician rather than as another damned liposuction or botox specialist. While you're working in needed position X, the government would reduce your loan payments.posted by pracowity at 9:10 PM on November 18, 2008

Yeah yeah, the think tankers who have been studying this problem for years or decades, not to mention people in other countries have it all wrong. The correct solution is something someone just thought up off the top of their head in a random internet post. By the way, boosting the average tax rate by 0.05% would net you about $50 billion per year, which is enough for three primary care visits per person per year under your "plan". That's about the average, but it would cause people to avoid going to the doctor and therefore not get some medical conditions treated, which is one of the reasons our healthcare system is so fucked up.posted by delmoi at 9:38 PM on November 18, 2008

So the AMA wants to keep the insurance companies in business. How nice of them. Ever seen their buildings and the CEOs paychecks? How about their ability to get money from the FedGov, then pay for expensive trips?

Yea, lets work to KEEP the insurance firms afloat over the issue of human health.posted by rough ashlar at 9:56 PM on November 18, 2008 [1 favorite]

First of all it's 0.5% not 0.05%.

Second of all, it's not something through up off the top of their head. We've been doing it that way in our country for years and it's brought the best of both worlds to the table. While you can't switch the entire system to a single-payer overnight you can at least start with primary care. 0.5% should be more than enough to cover visits to the doctor and the single entity to deal with should free up most doctors from having to fight insurance companies and lower the number of administrative staff.

It would be dead easy to get started too. Issue a health care magnetic card to all Americans and a mag stripe reader to all doctors. Swipe the card, reader transmits back to the federal agency base, agency figures out how many appointments the doctor saw and sends through the funds automatically.

Personally I wouldn't trade our current system for no-fee single payer care and I wouldn't trade it for a fully privatised system unless you pried my Medicare card from my cold dead fingers.posted by Talez at 10:09 PM on November 18, 2008

I have a regular doctor (GP) and a pretty good health plan. When I'm ill and go in to the doctor's office, 2 out of 3 times the person who sees me is a random physician's assistant, no matter how minor or serious the symptoms. I've talked to my doc about this, and she apologetically says that she has to take so many patients that she can't really take care of all of them.posted by zippy at 10:20 PM on November 18, 2008

zippy:I have a regular doctor (GP) and a pretty good health plan. When I'm ill and go in to the doctor's office, 2 out of 3 times the person who sees me is a random physician's assistant, no matter how minor or serious the symptoms. I've talked to my doc about this, and she apologetically says that she has to take so many patients that she can't really take care of all of them.

Maybe the solution would be to train more physician's assistants and let them handle more? Whenever I've seen them, they've seemed pretty competent, and the length of education a PA receives sounds quite similar to what a general practitioner gets in the rest of the world. A lot of the stuff people see doctors for, they really don't need to - colds and flues and whatnot. They just need someone reasonably competent to say on one end 'no, you do not need vancomycin for your cold' and on the other end 'yes, you should probably see someone about that piece of steel protruding from your head.'posted by Mitrovarr at 10:38 PM on November 18, 2008

What's wrong? Why would "nearly half of all primary care physicians leave medicine if they had a viable alternative"? One word for ya:

GOMERS.

Get. Out. of. My. Emergency. Room. ie. Hypochondriacs.

Then add to that a tidal wave of dumb people who have got health problems because of their own stupidity. [is there an acronym for that?] Then add to that the ass reaming you get when you are just so sooo jaded and don’t run the full barrage of tests and some poor innocent person has cancer and you miss it.

I have worked as a health professional at the proactive / preventative side of things and it’s enough to drive you bonkers. I can understand how soul destroying it would be to work on the reactive / curing side of health.posted by uncanny hengeman at 12:09 AM on November 19, 2008

I live in England: I don't recognise this at all. As an end user, My health care is simpler than my car insurance. My interactions with the service have been prompt, professional and helpful. Any shortcomings must take into account the fact we spend less as a proportion of national wealth on healthcare than other European states and the United States, and that we have shifted many social problems (e.g. mental illness) from social to health services. So we spend half as much money and get a better system for everyone but the very rich.

I simply can't imagine how it must be to worry that if I lose my job I also lose the ability to take my children to the doctor. How does this make any sense?

The American antipathy to public healthcare is, like guns and religion, one of the things that makes this very similar people suddenly seem very alien to this Brit. Like guns and religion I think there is more sentiment than sense behind it.posted by alasdair at 12:36 AM on November 19, 2008 [4 favorites]

What's wrong? Why would "nearly half of all primary care physicians leave medicine if they had a viable alternative"? One word for ya:

GOMERS.

Get. Out. of. My. Emergency. Room. ie. Hypochondriacs.

Then on the other hand you have the folks who complain when people ask about their health concerns on Ask MetaFilter instead of going to the doctor.

I've often felt there's a Catch-22 here. If you you ask non-doctors for advice, you're irresponsible because they aren't qualified to answer. But if you visit the doctor, you're irresponsible because your concern isn't worth their time.posted by grouse at 12:43 AM on November 19, 2008 [3 favorites]

Regarding med students who do it for the $$$ and the cross-border brain-drain into the USA and specializations:

My older sister went to the medical school at the University of Western Ontario back in the late 90s, when medical school in Canada was heavily subsidized and the tuition was regulated by the state to stay within the same range as a regular undergrad tuition (about $5000 CDN). My little brother went to the same med school back around 2004, after tuition had been deregulated and was rising from $15000 to $20000.

The difference between the classes couldn't be clearer. My sister's class was from a diverse set of backgrounds, including children of 1st-generation immigrants, working class kids, and rural kids, all of whom could pay their way through school with summer jobs and small loans. These were students that were largely not obsessed with the higher pay rates offered by particular specializations or the US job market, instead often choosing careers that served the communities where they came from (i.e., a "helicopter" GP in Northern Ontario, a psychiatrist to the urban homeless community in Toronto, a pediatrician for immigrant families).

My brother's cohort paid much larger tuition, and this showed in two ways: 1) Only wealthier, more priviledged kids could afford the program, most of whom did not feel an obligation of service to their communities of origin; 2) most of them still had to take out massive student loans to pay the tuition yearly, which placed tremendous pressure on them to pay off their debts as soon as possible. As a result of this latter circumstance, my siblings noticed the following differences: a) a strong sense of student entitlement in the program (i.e., "My parents didn't pay $20000 / year for you to fail me on this exam); b) a spike in cheating on coursework; c) an intensification of competitive attitudes between students; d) an obsession with getting into the highest-earning specializations; e) a shift in how they imagine a doctor's lifestyle (i.e., no longer community service, now luxury and high social status); f) most worryingly, an increase in dehumanizing attitudes towards patients, who are increasingly seen as walking pay-cheques whose desire for comfort and care is inconvenient and annoying.

Of course, neither of these sets of generalizations apply across the board. There was at least asshole narcissist sociopath in my sister's class, and there were a couple of service-oriented med students in my brother's class (although it's hard to tell, since the most strategic careerists learned to parrot the "save the world" rhetoric to get ahead). But nonetheless my siblings (and my mother, who is also involved with the school) have been making these comparisons for years with countless examples at the dinner tables.

In other words, making medical training affordable for the not-so-wealthy without requiring massive debt encourages young doctors to be motivated by something other than lucre.

I know that I'm a lot less nervous in a Canadian hospital than an American one. The quality of care is identical, if not superior (maybe because they're not profit driven) and fears like "I hope this is covered" and "omigod this might cost me my house" is strangely missing.

Hell, I had great care for a surprise emergency in Cuba once. I think it cost $30, and I spent at least an hour with a doctor.

Agreed, grouse. Catch 22s all over the place. And I'll be the first to admit I'm being somewhat elitist.

I've got a solid grounding in human biology and physiology. As well as working in the periphery of the field I just happened to work in a venue where a health-related-industry training school hired our space, and hence befriended a few lecturers, I have got numerous doctor / physio friends.... I'm an extremely lucky boy.

ie. I'm clever enough to listen to non-qualified-doctor advice similar to what can be found on AskMe and work out if it's horseshait or not - 99% of the time. And I can go to a doctor with a problem and not waste their time, even self diagnose somewhat (although you have to be careful there - that's a bit rude!).

I am continually surprised by just how dumb people can be. Even a lot of my nearest and dearest are morons, health knowledge wise. I don't have any answers except clichés, look after yourself, don't be lazy, try and stay informed, blah blah.posted by uncanny hengeman at 1:04 AM on November 19, 2008

I simply can't imagine how it must be to worry that if I lose my job I also lose the ability to take my children to the doctor. How does this make any sense?

In the U.S., your job is your identity. Why, if you don't have a job, how can you buy things? And we all know you can judge the worth of a person by their accumulation of stuff--often at the expense of others (in fact, this is encouraged). I believe it has something to do with the crazy religious nuts that you kicked out of Europe in the 16th & 17th century. Most of them landed here and founded whole societies on their fanatical beliefs. Their fanaticism is part of our shared cultural history.posted by Civil_Disobedient at 2:01 AM on November 19, 2008

I live in a small, relatively poor minnow country in Europe (population: 2 million) that has nevertheless managed to provide quality universal health care for everyone. (According to the WHO, the quality of health care in Slovenia is roughly equal to the United States.)

When I first moved here (from the U.S.) I was pretty much expecting the worse: long lines, apathetic doctors, old equipment, the gratuitous and widespread use of leeches, etc... I was dead wrong. The system here is tremendous. I wait for five minutes, my doctor is patient and knowledgeable, and medicine is "free." Do I pay high taxes? You bet your ass I do. But besides getting health care whenever I need it, I also have two critical advantages that I didn't have in America:

1) I will never have to worry about going bankrupt because of some unforeseen medical problem.

Both of those things are priceless to me. And regarding the second point: A few years ago, an acquaintance of mine here gave birth to a boy with a deformed skull. The kid's life was in danger, and since the country didn't have the necessary specialists to treat him, they flew the family to France and had the surgery done there. Total cost to her: €0.

Her story was pretty much the tipping point for me. I mean, who gives a shit paying extra taxes if the final goal is to make sure people don't have to bury a child who might have otherwise been saved?

England is a health care nightmare! Since I have moved here I have had to deal with filling out one form at the local clinic and doing it again when I moved to a new neighbourhood. Two forms in three years is two too many! I've had to take free antibiotics and live with the constant pressure of knowing that if something is wrong I can go to the doctor right away. To make the pressure even worse the Medical Clinics are local! Within walking distance. Where is the fun in that? You have no idea the terrible burden it is to live in a regulated and subsidized health-care market. What's worse is that my neighbours have the same access that I do! How can I feel good about being healthy if my neighbours are just as healthy?posted by srboisvert at 3:30 AM on November 19, 2008 [7 favorites]

Then add to that a tidal wave of dumb people who have got health problems because of their own stupidity.

Would that be from over eating, lack of excersize, eating things like HFCS or transfats, or just when someone runs their hand through power equipment?posted by rough ashlar at 4:38 AM on November 19, 2008

This is a nonproblem. As long as we can keep sapping the rest of the world's medical graduates, we'll have just enough docs to scrape by without needing to reform anything. As for the other countries, nuts to them I guess.

The residents and interns talked about in the blurb of your second link are required to stay in their home countries for at least two years before they can come back to the US unless their home country is willing to say they don't need them.posted by Pollomacho at 4:49 AM on November 19, 2008

Then add to that a tidal wave of dumb people who have got health problems because of their own stupidity.

You mean like trusting their health care to judgmental, elitist pricks?posted by Thorzdad at 6:22 AM on November 19, 2008 [2 favorites]

Then add to that a tidal wave of dumb people who have got health problems because of their own stupidity.

Completely true. Let's face it, we'd save trillions if we started people on an educational path that gave them the most rudimentary sense of the connection between long term health and lifestyle. More than half my work would vanish if people exercised once a week and ate properly. I rarely see this discussed when the idea of Universal Health Care is considered, but it's no different than discussing any other resource like oil and refusing to consider the issue of fuel efficiency and consumption. People's individual choices have an impact on the larger societal burden of cost-of-care. Making shrill rejoinders about personal freedoms to piss away your health doesn't accomplish anything. The reason many people are dissatisfied with their doctors is that the doctor knows anything they suggest is hopeless when it comes to the numerous chronic, insoluble complaints of people that smoke, are obese, or who will not exercise and come in with complaints of feeling chronically tired, achey, or depressed.

We'd be completely fine with any single-payer system. A lot of physicians would have to adjust to lower pay, a whole generation of Americans would have to be retrained to think differently about health care and personal behavior, and in one to two generations our current system would seem as unfortunate, antiquated, and embarrassing as segregation.posted by docpops at 7:22 AM on November 19, 2008 [1 favorite]

Let's face it, we'd save trillions if we started people on an educational path that gave them the most rudimentary sense of the connection between long term health and lifestyle.

Let's ban all pharmaceutical ads and require Big Pharma to fund this with the money they save.posted by vibrotronica at 8:28 AM on November 19, 2008 [1 favorite]

More than half my work would vanish if people exercised once a week and ate properly.

I'd also add that people would be healthier if they could afford to take time off to exercise. The short-term economic demands of working 1.5 - 3 jobs (feeds the kids and puts a roof over their heads) makes it harder to achieve the long-term benefit of exercise.posted by zippy at 9:05 AM on November 19, 2008 [1 favorite]

Here is the system:
1) Medicare sets what and how much they will pay docs
2) The AMA advises Medicare what it should pay (indirectly)
3) AMA is composed primarily of specialists
4) Primary Care thusly shafted

Also of note, back in Massachusetts when they went with their system that required everybody to have insurance the wait time for a general physical went to 9 months.

You can't see the shortage in primary care until the ER closes to non-emergent folks, or they allow them to be turned away.

But back to the original post, the thing is that really kills us is all the non-medical paperwork that we do that takes us away from our patients (paid or not).posted by mbigouben at 9:20 AM on November 19, 2008

Zippy - go to any gym at 5 am and talk to those people. You're absolutely right, but it's still a matter of will. Even when I'm post-call and have 4 people to round on between 6 and 7:30 am I still show up to swim and lift weights before starting work.posted by docpops at 9:22 AM on November 19, 2008

I'd also add that people would be healthier if they could afford to take time off to exercise.

Even the overworked manage to take a lot more than an hour a week off for television.

Also, like: walk to work, people.posted by rokusan at 10:50 AM on November 19, 2008

I don't think the main problem here is education. I'm pretty sure almost every obese person and smoker consciously knows that their general health would improve dramatically if they ate right, exercised, and quit smoking.

The problem is internalizing this belief, and having the willpower to follow through on it. Both of these are cultural, and frankly American culture is rubbish about sending the right messages here. We're bombarded constantly with exactly the wrong messages:

Happiness is a dripping cheeseburger, a la-z-boy, and a TV screen.

Being "fit" is defined as bone-thin with big boobs (for women) or a top-heavy mass of veins and bulging muscle (for men). If you aren't going to attain these "ideals", you will never be fit.

Corollary to the above: exercise is only worthwhile as a means to those ideals.

Taking a pill to solve a medical problem is easier and better than working to avoid it in the first place. In fact, forget we even mentioned that it can be avoided in the first place. (here, we have a pill to help you forget)

These messages are funded by the people with the deepest pockets in the status quo, and the only comparable influences (the media, the government) have their hands inextricably buried in those same pockets.

We need a completely new American zeitgeist when it comes to health, and we need it yesterday.posted by Riki tiki at 1:52 PM on November 19, 2008

Ugh. My last post came out terribly. It was all me me me! Last attempt... What I'm trying to say is:

I have a thousand times more sympathy for a person who has gotten themselves into a financial pickle thru lack of knowledge and naivety than people who have gotten themselves in a health pickle thru lack of knowledge and naivety.

There are veritable armies of crooks out there dedicated to swindling money out of chumps. Bad health is a lot more often people's own doing.

I don't think you have to be that intelligent to get the basic armoury and skills to not get sick because of stupidity. But you at least have to try.

"I was ill informed and never bothered to learn anything about health and now I want an expensive heart operation for free."

That and all the other brilliant posts above, about the med schools churning out undesirables these last 20 years.posted by uncanny hengeman at 3:10 PM on November 19, 2008

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